Form DHS Form 10008 DHS Form 10008 Application for Safety Act Designation

OMB Control No. 1640-0001
Expires: 03/31/2013

APPLICATION FOR SAFETY ACT DESIGNATION
The purpose of completing a SAFETY Act Designation application is for you, the Seller of a
Technology, to explain to the Department how your Technology qualifies for the system of
risk management and litigation management under the SAFETY Act. The questions are
designed to elicit the information that will allow the Department to understand exactly what
it is that you sell and how it relates to the criteria for Designation set forth in the Act. Not
all questions will be applicable to all types of technology – this is unavoidable given the
broad range of potential types of qualifying technologies. If a particular request or question
does not seem relevant to your Technology, explain why you do not think it is relevant in
your response to that item. In addition, the Department will accept any supplemental
information regarding your Technology that you wish to provide. It is particularly important
to identify any prior use or ongoing procurements of your Technology by the military,
Federal Government agencies, or State, local, or foreign governmental entities. Prior
Government use or procurement may significantly expedite the application process.

(Designation Application Form on following page)

Privacy Act Notice: DHS Authority to Collect This Information: 6 U.S.C. §§ 441–444 (the “SAFETY Act”) and 6 C.F.R. Part 25, 71 Fed. Reg.
33147, 33159. Principal Purposes: DHS collects telephone numbers, addresses, and other identifying information for the purpose of contacting
individuals seeking liability protections on issues related to the SAFETY ACT application process. Routine Uses and Sharing: In general, DHS will
not use this information for any purpose other than DHS personnel contacting the individual. However, DHS may release this information of an
individual on a case-by-case basis as described in the S&T SAFETY Act System of Records Notice (SORN), which can be found at:
www.dhs.gov/privacy. Disclosure: Submission of this information is voluntary and an individual may opt not to provide the requested information
or to provide only some of the information DHS requests. If an individual chooses to opt not to provide some or all of the requested information,
DHS may not be able to process the individual’s request.
PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 16400001 and this form will expire on 03/31/2013. The estimated average time to complete this form is 80 hours per respondent. If you have any
comments regarding the burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC
20528.
DHS Form 10008 (10/06)

Application for SAFETY Act Designation
APPLICATION TYPE
D1. Type of Application. This application is a(n) (choose one):
Initial Filing
Application following a Pre-Application Consultation
Application ID #:__________________________________________
Resubmission of a Previous Application
Application ID #:__________________________________________
Application for Renewal of Designation:
Application ID #:__________________________________________
D1.1 Public Web site Listing
If your Technology is awarded SAFETY Act coverage, you have the opportunity
to be listed on the SAFETY Act Web site as a Designated Seller of a Qualified
Anti-Terrorism Technology (QATT). [For example, if you apply for Designation
and Certification and receive Designation, your Technology will be listed under
Designated Technologies. Or, if you are granted DT&E Designation, regardless
of which protection you applied for, you will be so listed on the Web site. Note:
By statute, all Certified Technologies will be displayed in the Approved Products
List for Homeland Security on the Web site.]
I wish to have my QATT listed on the public Web site under the appropriate
classification.
I do not wish to have my QATT listed on the public Web site under the
appropriate classification.
EXPEDITED REVIEW
D2. Request for Expedited Review
In its discretion, the Department may identify categories of anti-terrorism
technologies for which expedited processing may be granted. For example, the
Under Secretary may conduct expedited processing for applications that are the
subject of a pending Federal, State, or local procurement, that address a particular
threat, that involve particular types of anti-terrorism technologies, or for other
reasons. If you are requesting expedited review, please specify the basis for such a
request, including, if applicable, information concerning an ongoing procurement.
Such information should include the following:
DHS Form 10008 (10/06)

a. The name of procuring organization;
b. Contact information for relevant Government procurement officials;
c. The related Request for Proposal (RFP) number or other official identifier
of the procurement, if available; and
d. Upcoming deadlines relating to the procurement (e.g., submission
deadline, decision/contract award, etc.).
Please note if your application falls under a published DHS Notice of Expedited
Processing, provide the reference number for such Notice, and a brief statement
as to why your application falls within the scope of the Notice. If you wish to
provide other bases for expedited processing, please specify.
REGISTRATION INFORMATION
D3. Registration Status (choose one):
My initial Seller registration is included with this application.
I am updating or correcting previous registration information.
My previously provided registration information is still accurate.
D3.1. Seller Name: ________________________________________________________
OVERVIEW OF THE ANTI-TERRORISM TECHNOLOGY
D4. Non-proprietary Summary
D4.1. Name of your Technology: ____________________________________________
D4.2. Company and Technology Description. Provide an overview of your
company, including business structure, place of incorporation, company
history, a description of your business, and a brief, two-line description of the
Technology that is the subject of this application. This description of your
Technology should be non-proprietary, that is, appropriate for public viewing
on the SAFETY Act website if approved for SAFETY Act coverage.
____________________________________________________________
____________________________________________________________
____________________________________________________________
_______________________________________________________________
D5. Summary of your Technology. Please provide a brief (no more than two-page)
overall description of your Technology. If your Technology is a product or device,
please describe the Technology, including its principal elements, subsystems and
components. If your Technology is a service, please provide an overview of the
nature of the service, the actions, activities, planning, training, and/or expertise
involved in providing the service and how the service is designed to counter
terrorist threats. If your Technology is an “integrator” of various products,
DHS Form 10008 (10/06)

services, or legacy systems, indicate how the Technology will integrate the various
component parts.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
D6. Past Sales and ongoing procurements. Note: It may be very important and could
significantly expedite your application if your Technology has been acquired or used
(or is subject to an ongoing procurement) by the military, a Federal Government
agency, or a State, local or foreign governmental entity.
D6.1.

Who has purchased or plans to purchase your Technology? (Choose all that
apply.) Please provide a brief description of such purchases.

Federal Government (Agency: _____________ Approximate Date: _______ )
State Government (State: ________________ Approximate Date: _______ )
Local Government (City/County: __________ Approximate Date: _______ )
Commercial organization (Name: ___________ Approximate Date: _______ )
Foreign Government (Name: ______________ Approximate Date: ______ )
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
D6.2. Contact information. Include name, address, phone number, and e-mail
address or procuring officials, if available. If POCs are provided as sources of
information or testimonials, check below to indicate that you have contacted
DHS Form 10008 (10/06)

them and that they are expecting to hear from DHS related to your
Technology. Also, indicate below what information we should expect from
each POC.
The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________
D6.3. If applicable, provide information regarding your Technology’s use by the
United States Government or by any State, local, or foreign Government.
D6.4. Please identify any determination made by Federal, State, or local Government
officials in any past or ongoing procurement or other context that your
Technology is appropriate for the purpose of countering terrorism.
D7. If any other corporate entity or entities should be identified as an authorized Seller
of the subject Technology in addition to the firm identified in the response to D3.1
above, please identify each entity and the place in which it is organized.
D8. Provide the earliest date of sale of the Technology for which you are requesting
SAFETY Act coverage. This should represent the date that the Technology was
first deployed, used or modified to be used in an Anti-terrorism context. Please
provide a justification of the date used.
DESIGNATION AS A QUALIFIED ANTI-TERRORISM TECHNOLOGY
Respond to all items in this section in one attachment to this application.
Additional supporting material may be attached as an appendix to your
application.
D9. Description of your Technology. One of the most important parts of the
application process is defining the scope of your Technology. In this section,
define your Technology with a sufficient degree of specificity. This description will
serve as the basis for the Department’s analysis of your Technology for SAFETY
Act purposes. The content of the response you provide in this section, together
with any additional information you may be asked to provide, may be used to
finalize the definition and scope of your Technology as it will appear in a
Designation. Refer to the instructions for a more detailed example.
D10. Deployment and Operation. Describe the sequence of steps involved in deploying
and operating your Technology. Provide sufficient detail to show that your
company is capable of supplying your Technology. Be specific about all activities
DHS Form 10008 (10/06)

such as the development, implementation, operation and management, etc. required
to deploy your Technology.
D11. Readiness for Sale. How ready is your Technology to be sold and deployed? Please
describe any modifications, adjustments, start-up time, hiring and vetting of
personnel, building of manufacturing facilities, or other processes which might be
required prior to a new deployment.
D12. Magnitude of Risk. Please provide an assessment of the magnitude of risk to the
public from the type of terrorist activities your Technology would counter. Please
describe, to the extent practicable, the scope of the injury, property or other
damage, economic loss, loss of life, or other harm that could result from such
terrorist activity. Please describe how the Technology has been deployed to date
and how it can counter terrorist activities.
D13. Please describe how your plans for selling, deploying, or maintaining your
Technology would be affected if the Department does not issue a SAFETY Act
Designation for your Technology. Please describe how the Technology will be
deployed in the future if SAFETY Act Designation is issued.
D14. Effectiveness and Utility. Provide information supporting the potential for your
Technology to be effective in countering potential acts of terrorism. Please provide
internal or external effectiveness tests or other information indicating the
effectiveness of your Technology. This can include acceptance test data from a
Government contracting action, penetration tests, case studies, pre and posttraining testing, incident reports, customer feedback, or other relevant data or
experience. As noted, acceptance of your Technology by a Government purchaser
may be highly relevant and expedite approval of your application.
It is important that effectiveness data be in documented form if at all possible. You
are responsible for providing all documentation in support of your application at
the time of submittal, or to facilitate the transfer of any such information prior to
submission. In the event that obtaining documentation is not possible and if
POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from
DHS related to your Technology. Also, indicate below specifically what
information we should expect from each POC. Please see the Instructions for
additional information.
The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________

DHS Form 10008 (10/06)

____________________________________________________________
____________________________________________________________
D15. Include any other information the Department should consider in evaluating your
Technology.
Documents in support of your Application should be uploaded as Attachments
together with a separate numbered Table of Contents document. Please refer to
the instructions regarding “Additional Attachments.” If POCs are provided as
sources of information or testimonials, check below to indicate that you have
contacted them and that they are expecting to hear from DHS related to your
Technology. Also, indicate below what information we should expect from each
POC.
The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
D16.

Insurance Data

D16.1. Please provide the information indicated below for any and all current
liability insurance policies that are available to satisfy otherwise compensable
third-party claims arising out of, relating to, or resulting from an act of
terrorism were your Technology deployed in defense against, response to, or
recovery from such act:
a. Primary named insured (as it appears on your insurance policy).
b. Additional named insured relevant to the Technology Sellers.
c. Type of policy (ies) (e.g., Comprehensive General Liability, Errors and

Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.)
d. Policy Dates. (Start and end)
e. Insurer.
f. Per-occurrence limits.1
g. Aggregate limits.

1 Please indicate whether the policy (ies) has a different limit or deductible/self-insured retention for

terrorist acts than the general policy limit and, if so, provide both.
DHS Form 10008 (10/06)

h. Annual Premium(s).2
i.

Deductible(s) or Self-insured retentions.

j.

Exclusions (please note and explain any pertinent insurance exclusions, cancellation
terms, or limits that would potentially dilute or eliminate the availability of coverage under
the policies identified in sub-paragraph “c” above).

k. Please describe the type and limits of terrorism coverage for this policy.

Please elaborate on the applicability of the policies identified in subparagraph “c” to address the foreseeable risks associated with the
deployment of the Technology, including those risks arising from the
deployment of the Technology in advance of or response to an act of
terrorism. Please also indicate whether the identified policy(ies) provides
coverage under the Terrorism Risk Insurance Act (TRIA) of 2002, as
amended, or other insurance policy(ies) provisions or endorsements.
l. Please describe whether the relevant policy(ies) covers SAFETY Act claims
and whether the policy(ies) has a dedicated limit that applies to SAFETY
Act claims only or has a shared limit (i.e., shared with non-SAFETY Act
claims). Please indicate whether you have received a written interpretation
letter from either the carrier or insurance broker indicating whether the
policy covers SAFETY Act claims; if so, please provide a copy of such
document.
D16.2. Unavailability of Insurance
a. If you do not currently carry insurance for the Technology that would be
applicable in the event of an act of terrorism, please indicate the reasons. If
you have attempted to purchase insurance but it is not available on the
world market, please indicate the specific inquiries you have made. (You
may submit written communications from insurance companies or brokers
explaining why your Technology cannot be insured.)
b. If you have endeavored to purchase insurance but have not done so because
you have concluded that the cost of insurance premiums would
unreasonably distort the price of the Technology, please describe those
efforts to find appropriate insurance and state why you have concluded that
the cost of insurance for your Technology would unreasonably distort its
sales price. In this context, you may need to provide an explanation with
relevant documentation (e.g., insurance quotes with limits, premiums,
exclusions, and other key items plus other relevant financial and market
data). Note: The Department recognizes that the discussion of
requisite insurance with an Applicant may require a number of

2 Insurance premium: If possible, please indicate what percentage of the premium is allotted to coverage

for acts of terrorism.
DHS Form 10008 (10/06)

communications while an application is pending. Thus, the question
of whether a given premium would “distort the sales price” of a
Technology might not arise when the application is submitted. If the
question does arise later in the process, the Applicant may submit
appropriate information at that time.
D16.3. Insurance Point of Contact
If POCs are provided as sources of information or testimonials, check below
to indicate that you have contacted them and that they are expecting to hear
from DHS related to your Technology. Also, indicate below what
information we should expect from each POC.
The POCs are expecting contact from DHS. The information the POC
can provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________
D16.4. Revenue Projection
In order for us to determine the amount of insurance that would not
unreasonably distort the sales price of your Technology, we need you to
provide us with three (3)-year projected (prospective) revenue estimates for
your Technology - all assuming that your Technology is approved under the
SAFETY Act. The three-year period should include your current fiscal year,
if incomplete, and two subsequent years.
If you do not have current year sales for your Technology, please provide us
with three (3)-year projected revenue data.
The revenue data needs only to pertain to your Technology and the numbers
need only be summarized data (that is, we do not require the revenue
sources to be itemized). The revenue data should be matched with
summarized cost data (e.g., cost of goods sold); as with the revenue data, we
do not require breakdown of data by cost centers.
D16.5. Deployment. Please establish how the deployment of your Technology as an
anti-terrorism technology would expose you to extraordinarily high liability
and what this liability might be. This can be accomplished by developing a
plausible scenario that establishes how the Technology could be the
proximate cause of third-party claims in the event of an act of terrorism.
Please make the scenario and third-party liability claims specific to the
deployment and use of your Technology.

DHS Form 10008 (10/06)

D17. Financial Data
Certain financial information regarding your company and projected/prospective
Technology revenue may be particularly relevant to the application process. This is
particularly true when questions arise as to whether insurance costs for specified
coverage limits unduly distort the price of your Technology. We may request
additional financial information from the Applicant if necessary during the
application process.
D17.1. You may provide a copy of the Seller’s financial statement for the most
recent fiscal year. For public companies, the most recent SEC annual report
(Form 10-K) and SEC quarterly report (Form 10-Q), together with any
amendments thereto, should suffice. For non-publicly traded companies,
you may choose to include the following information for the most recent
fiscal year: income statement, statement of cash flow, and balance sheet as
well as pro forma financial statement. OSAI will seek additional and more
specific information only when necessary for a particular application.
ADDITIONAL ATTACHMENTS
Provide all supporting documentation. Please see the instructions for further
information.

DECLARATION FOR WRITTEN SUBMISSIONS
I declare, to the best of my knowledge and belief, that the information provided in
response to the questions set forth in this Application for SAFETY Act liability protections
is true, factual, and correct, and that I am an authorized agent of the Applicant.
Prepared By: ________________________________

Title (if applicable): _______________

Signature: ______________________________________________ Date: ___/___/20__

The signature of the Preparer must be notarized below:
State of:

_______________

Subscribed and sworn before me this

Notary Public:

_____

day of

_____________________

___________________________________________________

My Commission Expires on:

DHS Form 10008 (10/06)

County of: __________________________

________________________________________

Instructions for Completing Designation Application Form:
Application Type

Item D1. Type of Application
If you have not previously filed an application for SAFETY Act liability protections
for this Technology or have not filed a request for Pre-Application Consultation,
check “Initial Filing.”
If you have filed a request for Pre-Application Consultation regarding this
Technology but have not previously filed an Application for SAFETY Act
Designation as a Qualified Anti-Terrorism Technology (QATT), check the second
box: “Application following a Pre-Application Consultation.”
If you have previously applied for SAFETY Act liability protections for this
Technology, check the third box: “Resubmission of Previous Application.” This case
applies if any previous applications for this Technology were withdrawn, found to be
incomplete, or were declined. Previously incomplete or declined applications will not
affect the evaluation of your current application; this information is requested for
administrative and record-keeping purposes only.
If you are filing this form in order to apply for renewal of a Designation, check the
fourth box: “Application for Renewal of Designation,” and enter the identification
number of the Designation you are renewing as it appeared on your original
notification. For renewal applications, you must complete all items but may respond
with “No changes” to items that have not changed since your last application for
Designation or approved Modification Notice. Wherever you have additional or
revised information since your last Designation application or approved Modification
Notice, complete that item as directed.

Expedited Review
Item D2. Request for Expedited Review
In its discretion, the Department may identify categories of anti-terrorism
technologies for which expedited processing may be granted. For example, the
Under Secretary may conduct expedited processing for applications that are the
subject of a pending Federal, State, or local procurement, which address a particular
threat involving particular types of anti-terrorism technologies, or for other reasons.
If you are requesting an expedited review, please specify the appropriate basis for
expedited treatment of your application.
If your Technology is the subject of a pending Government procurement or if you
are planning to submit a proposal for a procurement decision in the near future,
provide the following information to the extent available:

DHS Form 10008 (10/06)

a. Name of procuring organization;
b. Contact information for relevant Government procurement officials;
c. Related Request for Proposal (RFP) number or other official identifier of
the procurement; and
d. Upcoming deadlines relating to the procurement (e.g., submission
deadline, decision/contract award, etc.).
If your request to expedite falls under a published DHS Notice of Expedited
Processing, check the appropriate box and follow the published instructions from the
announcement.
If your request to expedite is not related to procurement, please provide the basis for
your request and any available supporting information.

Registration Information
Item D3. Registration Information
Please check the appropriate box relating to your registration status.
Item D3.1. Name of Seller/Applicant
Enter your Seller name as listed on your registration form.

Overview of the Anti-Terrorism Technology
Item D4. Non-Proprietary Summary
Item D4.1. If this is the first application for this Technology, assign a name to your
Technology. This is the name that will appear on any Designation that may be
issued.
If you are applying for renewal of an existing Designation, use the name that appears
on your most recent Certificate of Designation or Modification Notice.
Item D4.2. The purpose of this item is to help the Department recognize potential
conflicts of interest and to avoid disclosing your application information to
inappropriate evaluators. The Department is committed to protecting your sensitive
business data from improper disclosure.
Provide a brief description of your company, including place of incorporation, a
description of your business, and the Technology that is the subject of the
Application. When describing your company, focus on identifying any affiliates that
will be involved with your Technology (e.g., parent companies, subsidiaries, joint
venture partners, holding companies, etc.). When describing your Technology, focus
on providing information that will help the Department identify which Subject
Matter Experts (SMEs) would be best qualified to evaluate your Technology. This
description should be no more than two sentences long and should be appropriate
for placement on a public Web site if your application for SAFETY Act coverage is
approved.
DHS Form 10008 (10/06)

The purpose of the company description and Technology description is to help the
Department recognize potential conflicts of interest and avoid disclosing your
application information to inappropriate evaluators. The Department is committed
to protecting your sensitive business data from improper disclosure. Do not include any
sensitive or proprietary information in this summary. If you wish to include information on
substantially similar QATTs or provide information regarding who your major
competitors are with respect to the subject Technology, you may do so.

Item D5. Nature of Your Technology
Please briefly describe the nature of your Technology in two pages or less. The
SAFETY Act applies to a broad range of anti-terrorism technologies. In your
response to the question, please describe whether your application is for an antiterrorism product, service, combination of products and services, information
technology, or some other form of intellectual property. If your Technology is a
product or device, please describe the Technology in detail, including its principal
elements, sub-systems, and components. If your Technology is a service, please
describe the nature of the service, the actions, and associated services, activities,
planning, training, and/or expertise involved in providing the service and how the
service is designed to counter terrorist threats. If your Technology is an “integration”
of various products, services, or legacy systems indicate how the Technology will
integrate the various component parts.

Item D6. Past Sales and Ongoing Procurements
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate what information we should expect from each POC.
Item D6.1. What sales of your Technology have you made to date? Identify a
representative sale and approximate date for each category that applies. You may add
additional attachments as necessary. Please also specify anticipated sales of your
Technology.
Note: It may be very important and could significantly expedite your
application if your Technology has been acquired or used (or is subject to an
ongoing procurement) by the military, a Federal Government agency, or a
State, local, or foreign governmental entity.
Item D6.2. For each Federal, State, or local Government agency that has purchased
your Technology, provide contact information for one or two points of contact in an
attachment. For non-Government sales, provide one Point of Contact. For each
Federal acquisition, attach a copy of any Request for Proposals or Broad Agency
Announcements that led to the award and a copy of your final proposal and
Statement of Work.
For each customer, please indicate whether:

DHS Form 10008 (10/06)

•
•
•
•

The Technology has been fully deployed.
The Technology is in the process of being deployed.
The Technology has been purchased, but deployment has not yet begun.
The deployment is conditional on the Technology earning QATT status.

The Department will assume that any Point of Contact you provide has been given
permission to be contacted by DHS regarding your application.
If POCs are provided, please be advised that:.
1. The SAFETY Act may make contact with persons that you list as having
information to support the claims in your Application; however it is your
responsibility to make sure that you have provided all information to
support your Application at the time of submission. We suggest that you
obtain written testimonials from your customers.
2. If you choose to supply points of contact because you believe that thirdparties will be able to provide additional supporting information for which
you do not have access (such as for example, classified reports, audits,
vulnerability assessments, or other reports or data), remember to:
a) Be sure that the contact information you provide to us is
current.
b) Notify your references that you have submitted a SAFETY Act
application and that we may contact them.
c) Make sure that you are giving us the contact that will be able to
provide the best information on the nature of the past sale or
deployment, and on how your technology actually worked.
d) You may also supply contact information for third-parties, e.g.,
government officials, who might supply customer testimonials.
These individuals should be able to supply actual knowledge of
how your technology works and of its utility. We suggest that
you obtain this information in writing.
e) For past sales, provide the contact information for any purchase
referenced in D6.
f) For procurements, list the name and contact information for
the procurement officer or similar person in charge of the
contract, proposal, or Request for Proposal.
Item D6.3. Please provide information, if applicable, regarding how the United
States Government or any State, local, or foreign Government has used or is using
your Technology. You may also include information relating to your Technology’s
use by other entities and commercial deployments undertaken in coordination or
conjunction with Federal, State, local, or foreign Governments.
Item D6.4. Please identify any determination made by Federal, State, or local
Government officials that your Technology is effective and appropriate for the
DHS Form 10008 (10/06)

purpose of countering terrorism. Such determinations may have been made as part
of Government procurement, licensing action, or in other contexts. Note: It may be
very important and could significantly expedite your application if your Technology
has been acquired or used (or is subject to an ongoing procurement) by the military, a
Federal Government agency, or a State, local, or foreign governmental entity. As
appropriate, you should identify why the previously examined Technology is
appropriate for countering acts of terrorism or limiting the harm such acts might
otherwise cause.

Item D7. Seller
In certain instances, multiple corporate entities may appropriately be identified as a
Seller of the subject Technology. For instance, the Seller of the QATT could include
a parent company as well as subsidiaries or other affiliates. Your response will be
used to properly identify the Seller(s) of the QATT. If you would like multiple
entities to be considered a Seller of the QATT, please clearly and precisely identify
each of these firms and identify their respective place of incorporation.

Item D8. Earliest Date of Sale
This information will be used to specify the earliest date of sale of the QATT to
which the Designation shall apply. Please provide information on the significance of
this date. If the date is more than five years prior to the date of application, please
explain how you know your Technology has not significantly changed in that time
frame.

Designation as a QATT
Under the SAFETY Act, the Secretary of the Department of Homeland Security will
consider enumerated, non-exclusive criteria in evaluating a Technology for potential
Designation as a QATT. The Act gives the Secretary discretion in determining
whether to designate a particular technology as a QATT.
This section of the Application requests information that is necessary to evaluate
your Technology. Attach your responses to this section as one attachment. Not all
questions will be applicable to all types of technology. If a particular request or
question does not seem relevant to your Technology, do not leave a question blank
or merely refer to a previous response. Please contact the SAFETY Act Helpdesk to
request clarification.
This section must be presented in a narrative format, referring to each section below.
The ATT Details section should be written so that the reader may clearly understand
what your Technology is, what it does, and how it operates. The narrative sections
should consist of your claims about the capabilities, and effectiveness of your
Technology in an anti-terrorism context. It is important that all of your claims are
supported by relevant documentation in some manner. Depending on the nature of
your technology, e.g., product vs. service, that support would normally include such
items as case examples, test data, audits, assessments, reports, specification sheets,
DHS Form 10008 (10/06)

operating manuals, instructors manuals, performance reports, procedural manuals,
and the like. It is vital that you cross reference the supporting documentation to each
claim you make in order that our reviewers understand what material you wish us to
evaluate. You should also provide a Table of Contents listing as a separate attachment
which itself, lists your numbered attachments or exhibits.

Item D9. Description of your Technology
One of the most important parts of the application process is precisely defining the
scope of your Technology for evaluation and Designation. In order for the Secretary
to issue liability protections to your Technology, you must define with specificity
what that Technology is – that is, what you provide to your customers when you sell
that Technology, what it does, how it works, and what aspects of it are invariable
from deployment to the next. Note: embellishments, marketing materials, and
elements which cannot be substantiated in the rest of the application should not be
included. This Description is an expansion of that which you provided in Items D.4
and D.5, and will encompass the legal description of your Technology for any award
the Department may issue. In response to this section, include the following:
• Company name, business structure, additional sellers, and states of
incorporation, as applicable;
• Name of the Technology;
• Nature of the Technology;
• Purpose or intent of the Technology;
• Description of how the Technology works;
• A statement of where the Technology is intended to be utilized, e.g., in the
private sector, for the Federal government, for the military, etc.;
• A brief description (no more than two lines) of the type of terrorist attacks or
attempted terrorism acts the Technology is expected to counter; and,
• The principal elements, systems, or components provided to customers
(indicating, which components, if any, are optional)
The above elements as you provided in your Application will be translated into a
concise description by the Office of SAFETY Act Implementation, as in the
following example:
(Name of company, and any subsidiaries), a (State of Incorporation) company, provides the
(Name of technology) which is designed to (Purpose of the technology). (Name of Technology)
e.g., does this by (Briefly describe how it works) for ( Place of deployment or type of customer).
The Technology is used for the following anti-terror purpose(s) (type of threat). The Technology
includes the following elements:
• (list e.g., hardware and software )
• (list – e.g., integration services)
DHS Form 10008 (10/06)

• (list- e.g., training and consultation)
Note that for each component listed in your Technical Description, you must provide
support of capability and effectiveness. Your description should answer the
following questions:
• How and where may your Technology be used? If your Technology is a
device, address what training, if any, is necessary to use your Technology. If
your Technology is a service, describe what types of facilities you might serve
and how your Technology is tailored to providing anti-terrorism services at
those locations.
• Scope of your Technology: Briefly list the underlying principles or properties
that allow your Technology to perform its functions and achieve its purposes.
If your Technology consists of devices, briefly explain the operational
principles of those devices. If your Technology consists of services, explain
how those services are implemented to ensure consistent quality wherever
they are delivered and whether these services conform to recognized industry
standards. If your Technology consists of software, explain the key features
and algorithms. If your Technology consists of some other kind of product,
briefly explain how you produce that product. This information will help the
Department understand the precise scope of the Technology for which you
are applying for SAFETY Act coverage. If your Technology Description
encompasses too broad a scope, e.g., in areas of deployment or in threats
countered, you may be asked to provide separate Applications.
• What are the important elements that make up your Technology? That is,
what are the component processes, devices, software, or other contributing
activities and technologies that will be included in your specification? How
are they defined or delineated? Be aware that any ancillary components of
your Technology that are identified in your specification (e.g., manuals,
training, maintenance, etc.) should be supported in subsequent sections by
sufficient information to evaluate them. What parts of your business, if any,
are explicitly not included in this specification for purposes of this application?
Examples of component systems and activities of your Technology might include:
–
–
–
–
–
–
–
–
–

Equipment
Software
Software design
Personnel training and qualifications
Staffing
Algorithms
Consulting services
Systems integration services
Decision support systems or services

DHS Form 10008 (10/06)

–
–
–
–

Maintenance contracts
Periodic upgrades, post-deployment reviews
Testing services
Quality control features

If your Technology is primarily service-based, focus on describing the various
activities and sub-processes that contribute to the overall delivery of your service(s).
This information will help the Department understand the precise scope of your
Technology.
In addition to describing what you do, you should also briefly describe any elements,
processes, or activities that complement or interact with your Technology but that are
not specifically part of the Technology in this application and may be supplied by the
end-user. These might include other technologies you sell, activities performed by
your customers, technologies provided by other vendors, or parts of the public
infrastructure. This information will help the Department understand the precise
scope of Technology you are establishing in this specification. If your Technology
helps to integrate new components with legacy systems, please indicate that.
After developing this description, make sure that you refer back to it when
developing support for Items D.10 and D.14.

Item D10. Deployment and Operation
Describe the steps involved in the course of developing, producing and providing
your Technology to a customer. Using the Technology Description developed above;
you should provided documented support of your capability to provide all elements
of your Technology in these areas.
It is useful to begin by describing the sequence of steps involved in providing your
Technology to a customer, from initial contact to final deployment. Focus your
description on the process of producing and deploying your Technology, as opposed
to the end result or the nature of any specific tangible deliverable. Where possible,
include the estimated time required for each activity or step.
If your Technology involves physical products, your discussion might include
elements such as:
• Manufacturing capabilities (where will the Technology be manufactured, are
facilities in place, is there a manufacturing plan in place?)
• Production, including quality assurance, factory acceptance tests,
manufacturing standards, and the like.
• Installation and configuration plans, to include site acceptance tests
• Operation plans, operator instructions, and the like
• Training, including any user manuals or terms of use
• Maintenance and any maintenance records
• Monitoring
DHS Form 10008 (10/06)

• Upgrade policies
• Warranties and service contracts
• Post-deployment quality control
If your Technology includes software or information technology, please include
information such as:
• Software lifecycle development plans, including any verification, validation,
and accreditation (VV&A)
• Software upgrade policies
• Network architecture information
• Network security information
• Network stress testing
• Customer input into user access
If your Technology involves services, your discussion might include (as relevant):
• Pre-deployment work such as, Customer requirements analysis or site surveys
Staffing requirements, documentation of expertise, hiring and vetting policies
• Operational plans, policies and procedures, including items such as: post
orders and operational manuals
• Training, including: curriculum development, trainer’s notes, handouts, testing
materials, and presentation materials
• Post-delivery support and procedures
• Administrative and operational policy and procedure Documents
• Quality Control, to include: internal or independent audits, managerial
oversight at the local and corporate level, policy revisions, learned lessons,
etc.
Please see “Additional Attachments” below for instructions on supporting document
and classified materials submission.

Item D11. Readiness for Sale
If your Technology is not yet being marketed, estimate the time before your
Technology will be available for sale or will be sold at your planned maximum rate.
You should include any anticipated delays due to funding, required marketing,
required licenses or certifications, staffing, sub-contractor delays, etc.
If your Technology is already deployed, describe the deployments. Your description
should include the circumstances and the nature of the deployment of your
Technology. Provide sufficient information about the scope of the deployment that
addresses the following questions: (1) has it already been deployed? (2) Is it being
deployed? (3) Has it been purchased for deployment in the future? Information

DHS Form 10008 (10/06)

could also include the length of the deployment, the purpose of the deployment
(testing versus general use), and the types of customers using the Technology.
Your response should include an estimate of the time frame before your Technology
will be ready for sale or the time required for standing up a new deployment. This
should include a discussion of your recruitment, hiring, screening and training
procedures, as well as any procedures you use to retain your personnel. Relevant
policies should be uploaded as Attachments. Please reference all Attachments and
provide a Table of Contents.

Item D12. Magnitude of Risk
Please provide an assessment of the magnitude of risk to the public from the type of
terrorist activities your Technology would counter. Your response should identify
the types or categories of potential terrorist activities your Technology is intended to
address. Your response should also present, to the extent practicable, estimates of
the scope of the injury, property or other damage, economic loss, loss of life, or other
harm, including financial harm, that could result from such terrorist activity.
Additionally, please describe how the Technology has been deployed to date to
counter such terrorist threats.

Item D13. Impact of SAFETY Act Designation
Please describe how your plans for selling or deploying your Technology would be
affected should the SAFETY Act’s system of risk and litigation management not be
made available. Please describe how the Technology will be deployed in the future if
SAFETY Act Designation is issued. Within the response, please address how current
and future deployments of your Technology would be affected without SAFETY Act
protections. To the extent possible, include the likely effects of the excessive costs of
insurance on the price of the product, and the possible consequences thereof on
development, marketing, manufacture, qualification, sale, transportation, use,
operation, and support of the Technology.

Item D14. Effectiveness and Utility
The information you provide here should include information supporting your belief
that your Technology can be a valuable counter terrorism tool. The kind of
documentation you provide will depend on the nature of your Technology. You
should support each element, sub-component, or model listed in the Technology
Description which you provided in response to Item D.9. If you apply the same
supporting information to multiple elements, sub-components, or models, please
indicate why this is reasonable.
If your Technology is primarily a device or software product, your documentation
should emphasize available developmental and operational test data that indicate the
likely operating performance of that device or software. This could include
performance in past deployments, independent test results, Government licenses or
certifications, field tests (e.g. performance against simulated attacks), internal test
DHS Form 10008 (10/06)

data, customer studies, scientific studies of the techniques involved, industry reports,
Government or military publications, or any other documentation or experience that
suggests or supports the potential usefulness of your Technology. Please attach
copies of any such reports, publications, or evidence by using the additional
attachments sections that would facilitate analysis and evaluation of your Technology
by Subject Matter Experts (SMEs). Please reference all attachments in your response
and provide a Table of Contents in D.15.
If your Technology is primarily a service, your documentation should emphasize the
quality of the process whereby that service is delivered and should include any
available evidence of successful past deployments of a similar nature. In particular,
you should provide or cite information that documents any of the following:
• The results of independent and internal company audits
• The results of operational or tabletop exercises pertaining to this Technology
• Case histories of successful deployments or specific incidents indicating
effectiveness
• The repeatability of your processes for providing a core set of services prior to
any site or customer specific customization.
• Your methods for monitoring your adherence to your processes and to
industry standards, benchmarks or best practices.
The Department will not ordinarily conduct tests of your Technology for purposes of
SAFETY Act evaluation or compare your Technology directly to other similar
technologies. Reviewers will evaluate your Technology against the statutory criteria
for Designation primarily on the basis of the information you provide. Accordingly,
the information you provide in response to this question should be as comprehensive
and thorough as possible. It may be very important and could significantly expedite
your application if your Technology has been acquired or used (or is subject to an
ongoing procurement) by the military, a Federal Government agency, or a State or
local governmental entity. Procurements of your Technology by a foreign
Government may be relevant.
Please provide an overview narrative relative to the effectiveness of your
Technology, including references and summaries of supporting documentation. If
you reference any material that is not publicly available, it should be included as an
attachment to your application. If you refer to information provided elsewhere in
your application, cite it by internal title, item number, and the name of the
attachment. Even though your entire application will be treated as confidential, you
may (but are not required to) specially mark those portions of your application which
contain proprietary and/or business confidential information.
Please see “Additional Attachments” below for instructions on supporting
documents and classified materials submission.

DHS Form 10008 (10/06)

If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, please be advised that:
1. The SAFETY Act may make contact with persons that you list as having
information to support the claims in your Application; however it is your
responsibility to make sure that you have provided all information to
support your Application at the time of submission. Do not simply include
a listing of your customers for DHS to contact. We suggest that you obtain
written testimonials from your customers.
2. If you believe that third-parties will be able to provide additional
supporting information for which you do not have access (such as for
example, classified reports, audits, vulnerability assessments, or other
reports or data), remember to:
a) Be sure that the contact information you provide to us is
current.
b) Notify your references that you have submitted a SAFETY Act
application and that we may contact them.
c) Make sure that you are giving us the contact that will be able to
provide the best information on the nature of the past sale or
deployment, and on how your technology actually worked.
d) You may also supply contact information for third-parties, e.g.,
government officials, who might supply customer testimonials.
These individuals should be able to supply actual knowledge of
how your technology works and of its utility. We suggest that
you obtain this information in writing.
e) For past sales, provide the contact information for any purchase
referenced in D6.
f) For procurements, list the name and contact information for
the procurement officer or similar person in charge of the
contract, proposal, or Request for Proposal.

Item D15. Summary of QATT Qualifications
If you wish, you may use this item to summarize in broad terms why you believe your
Technology qualifies for SAFETY Act Designation. Please provide whatever
additional information that would be helpful to the Department in analyzing and
evaluating your Technology. You may refer to the specific criteria of the Act, or
suggest other relevant criteria, as you see fit. If you are providing attachments, please
provide a Table of Contents.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate what information we should expect from each POC.

DHS Form 10008 (10/06)

Item D16. Insurance Data
Document any and all current insurance coverage that would be available to satisfy
otherwise compensable third-party claims arising out of, relating to, or resulting from
an act of terrorism were your Technology deployed in defense against, response to, or
recovery from such an act and found to have caused harm. Please state whether such
policy includes Terrorism Risk Insurance Act (TRIA) coverage, as amended, or other
insurance policy(ies) provisions or endorsements that cover acts of terrorism. Please
specify any relevant exclusions or cancellation provisions that would limit the
availability of the current policies to satisfy third-party claims. Please also ensure that
the insurance coverage for all of the Sellers listed in D7., is contained in the answers
to the items below. In doing so, please be certain to specify whether the Seller(s)
is/are the primary insured or an additional insured.
If POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from DHS
related to your Technology. Also, indicate below what information we should expect
from each POC.
Item D16.1. Current Insurance
For item 16.1a, provide the name of the company identified as the primary insured
for the relevant current policy. If you are an additional insured instead of the primary
policy holder, please identify the primary insured and each other firm identified as an
additional named insured in item 16.1.b.
In item 16.1.k., specify the type of terrorism coverage provided under the referenced
policy(ies) (e.g., Terrorism Risk Insurance Extension Act, as amended, other
coverage, no terrorism exclusion). Please specify the overall and per-occurrence
limits that would apply to the terrorism coverage.
Item D16.2. Unavailability of Insurance
The SAFETY Act provides that a Seller may not be required “to obtain liability
insurance of more than the maximum amount of liability insurance reasonably
available from private sources on the world market at prices and terms that will not
unreasonably distort the sale price of Seller’s anti-terrorism technologies.” If you are
unable to obtain appropriate insurance, please provide information concerning your
attempts to obtain insurance coverage for your Technology (e.g., written
communications from insurance companies or brokers explaining why your
Technology cannot be insured). If insurance is available for terrorism events but at
rates which would distort the sales price of your Technology, document the prices of
that insurance and provide the relevant information to support how this would affect
the price of your Technology. You may wish to contact OSAI with questions
concerning what information would be most helpful to provide in response to this
item. Note: The Department recognizes that the discussion of requisite insurance
with an Applicant may require a number of communications while an application is
DHS Form 10008 (10/06)

pending. Thus, the question of whether a given premium would “distort the sales
price” of a Technology might not arise when the Application is submitted. If the
question does arise later in the process, the Applicant may submit appropriate
information at that time.
Item D16.3. Insurance Point of Contact
Insurance Point of Contact. Provide a point of contact, including telephone number
and e-mail address for someone authorized to discuss your company’s insurance
information with the Department. This point of contact may be the same person
identified in your registration statement and may be your counsel, insurance expert,
or any other person with appropriate information.
Item D16.4. Revenue Projections
Please provide us with three (3)-year projected (prospective) revenue data for your
Technology. The three-year period should include the current fiscal year, if
incomplete, and two subsequent years (best estimate). If you do not have current
year sales data for your Technology, please provide us with best estimate projections
for the three years following the launch of the Technology. The SAFETY Act
requires Sellers of anti-terrorism technologies to obtain liability insurance of such
types and in such amounts to satisfy otherwise compensable third-party claims arising
out of, relating to, or resulting from an act of terrorism when a Technology has been
deployed in defense against, response to, or recovery from an act of terrorism.
Technology revenue projections are of particular relevance in the application
process. This is true when questions arise as to whether insurance costs unduly
distort the price of your Technology.
Item D16.5. Deployment
Your response should identify the types or categories of potential terrorist activities
your Technology is intended to address. Your response should also present, to the
extent practicable, estimates of the scope of damage, loss of life, or other harm,
including financial harm, that could result from such terrorist activity. As noted in
the question, describe in a brief statement how the deployment of your Technology
as an anti-terrorism technology could expose your company to extraordinarily large or
unquantifiable potential third-party liability, and the potential range of the liability (in
U.S. dollars). We have found that use of a brief and concise scenario is a good means
to indicate how your Technology could expose you to third-party claims in the event
of an act of terrorism.

Item D17. Financial Data
Certain financial data may be used in the process for analyzing the appropriate
amount of insurance coverage for your particular Technology. This is particularly
true when questions arise as to whether insurance costs unduly distort the price of
your Technology. Accordingly, you may be asked to provide certain financial data to

DHS Form 10008 (10/06)

OSAI as part of your application. If this is the case, OSAI will not demand financial
information when it is not necessary for a particular application, and will not disclose
sensitive or proprietary information outside the application process. Applicants may
wish to provide financial data relating exclusively to the Technology.
Item D17.1. It may be helpful to attach your latest financial statement. If you are a
public company, your latest SEC 10-K annual report and SEC 10-Q quarterly report,
together with any amendments thereto, should suffice. If your company is not
publicly traded, you may choose to include the following information for the most
recent fiscal year: income statement, statement of cash flow, and balance sheet as well
as pro-forma financial statement. OSAI will seek additional and more specific
information only when necessary for a particular application.

Additional Attachments
In the process of answering the questions above, you might find it useful to attach
additional documents in support of your answers. These items can be included in
your application by using the “Additional Attachments” feature. When answering the
items above, it is appropriate to refer to attachments by name and or number.
Examples of common attachments might include, but are not limited to, the
following: test reports demonstrating the effectiveness of the Technology, operating
manuals, training manuals, project/program management plans, quality assurance
plans, quality control plans, copies of company certifications, results from pilot
studies, testimonials from customers, and warranties.
Submitting Documents as Attachments:
Documents in support of your Application should be uploaded as Attachments
together with a separate numbered Table of Contents document. Attachments
should be individually labeled and or otherwise clearly identified. For ease of use, we
prefer that documents are uploaded individually, rather than in a “Zip” file. Do not
submit the ATT Details Narrative document in write-protected format since that
information must be accessible to us for use in the creation of OSAI Program
documentation. Ideally, attachments should be cross referenced in your narrative
response, with clear indications of the purpose of the Attachment. It is usually
unnecessary to upload third-party material, such as government training
presentations, regulations or standards documents. You may refer to these
documents in your narrative and provide an open-source link. For additional
assistance in uploading documentation, or for further questions, please call the
SAFETY Act Help Desk.
Submitting classified or sensitive data or information:
In cases where the effectiveness data, e.g., audits or testing, that you wish to have
evaluated is classified or sensitive and is held by a third party; the Department will
attempt to assist you in obtaining this information, however, you MUST facilitate the
transfer of that data to the SAFETY Act office PRIOR to the submission of your
DHS Form 10008 (10/06)

Application. This means that you must notify the custodian of records for your
customer of your Application to the SAFETY Act and that Department requires
access to those records. Once you have completed this step, you must provide the
Department with the name and contact information of the holder of these records.
When a date has been set for the transfer of information, you may submit your
Application. For further assistance call the SAFETY Act Help Desk.
Declaration for Written Submissions
An authorized agent of the Applicant must, in the presence of a Notary, sign and date
this form before submitting it to OSAI. For electronic or Web submissions, follow
the instructions provided at safetyact.gov.

DHS Form 10008 (10/06)